Leadership and Management 7-10

Three Categories of Prioritization

1. "Don't do" 2. "Do later" 3. "Do now"

Strategic Planning as a Management Process Should Include the Following

1. A clear statement of the organization's mission 2. The identification of the agency's external constituencies or stakeholders and the determination of their assessment of the agency's purposes and operations 3. The delineation of the agency's strategic goals and objectives, typically in a 3- to 5-year plan 4. The development of strategies to achieve the goals

Internal Time Wasters

1. Accessibility to others 2. Technology (Internet, gaming, e-mail, and social media sites) 3. Socializing 4. Interruptions—be brief 5. Paperwork overload 6. A poor filing system

Steps in the Budget Process

1. Assess what needs to covered in the budget. 2. Diagnosis of the goals for the budget 3. Plan for the budget cycle. 4. Implementation or ongoing management and analysis of the budget 5. Evaluate and periodic review of the budget for the fiscal year.

Bran's 12 Habits to Master Time Management

1. Strive to be authentic. 2. Favor trusting relationships. 3. Maintain lifestyle that gives you maximum energy. 4. Organize day by your biorhythms. 5. Set very few priorities and stick to them. 6. Turn down things inconsistent with your priorities. 7. Set aside time for focused effort. 8. Always look for ways of doing thing better and faster. 9. Build solid processes. 10. Spot trouble ahead and solve problems immediately. 11. Break goals into small units of work and think only about one unit at a time. 12. Finish what is important and stop doing what is no longer worthwhile.

Organizational Philosophy Statement

A person should be able to identify exactly how the organization is implementing its philosophy by observing members of the nursing staff, reviewing the budgetary priorities, and talking to patients.

Budget

A plan that uses numerical data to predict the activities of an organization over a period of time The desired outcome of budgeting is maximal use of resources to meet organizational short- and long-term needs. A budget provides a mechanism for planning and control as well as for promoting each unit's needs and contributions.

A balanced scorecard is used to (Select all that apply.) Collect data. Gain clients. Develop metrics. Analyze data.

A. Collect data. C. Develop metrics. AND D. Analyze data.

Personnel Workforce Budget

Accounts for the majority of health-care organization's expense Health care is labor intensive. Next to personnel costs, supplies are the second most significant component in the hospital budget.

What is the goal of a budget? To predict an organization's activities To maximize the use of resources To help with planning and control All of the above

All

Which emotions are commonly associated with change? Pride Stress Loss Achievement All of the above

All

Which is an example of why plans might fail? Not enough alternatives Low motivation levels False assumptions Lack of sound strategies All of the above

All of the above

Principles of Good Planning

All plans must flow from other plans. Short-range plans must be congruent with long-range plans. Planning in all areas of the organization must follow the mission, philosophy, and goals of the overall organization. Planning involves the same process regardless of the period involved. The length of the plan is determined by what actions are necessary to make the plan successful. All planning must include an evaluation step and requires periodic reevaluation and prioritization. All people and organizational units affected by a plan should be included in the planning.

Three Cyclic Steps

Allow time for planning and establishing priorities. Complete the highest priority task whenever possible. Try to finish one task before beginning another. Note: Reprioritize based on remaining tasks and new information that may have been received.

Reminder

As a result of the PPS and the need to contain costs, the length of stay for most hospital admissions has decreased greatly.

Rules of SWOT Analysis

Be realistic about the strengths and weaknesses of your organization Be clear about how the present organization differs from what might be possible in the future Be specific about what you want to accomplish Always supply SWOT in relation to your competitors Keep SWOT short and simple Remember that SWOT is subjective

Rules as Part of the Planning Hierarchy

Because rules are the least flexible type of planning in the planning hierarchy, there should be as few rules as possible in the organization. Existing rules, however, should be enforced to keep morale from breaking down and to promote organizational structure.

Time Management Is Making Optimal Use of Available Time

Because time is a finite and valuable resource, learning to use it wisely requires both leadership skills and management functions. There is a close relationship between time management and stress. Good time-management skills allow an individual to spend time on things that matter.

Managed Care

Broadly defined as a system that attempts to integrate efficiency of care, access, and cost of care. Utilization review is a process used by insurance companies to assess the need for medical care and to assure that payment will be provided for the care. Capitation, whereby providers receive a fixed monthly payment regardless of services used by that patient during the month

Stage 5: Maintenance

Change is maintained and relapse is avoided.

Lewin (1951) Identified Several Rules That Should Be Followed in Implementing Change

Change should only be implemented for good reason. Change should always be gradual. All change should be planned and not sporadic or sudden. All individuals who may be affected by the change should be involved in planning for the change.

Three Good Reasons for Change

Change to solve some problem. Change to make work procedures more efficient. Change to reduce unnecessary workload.

Steps for Using Strategic Planning

Clearly define the purpose of the organization. Establish realistic goals and objectives. Identify external constituencies and determine their assessment of the organization's purposes. Clearly communicate the goals to the constituents. Develop a sense of ownership of the plan. Develop strategies to achieve the goals. Ensure that the most effective use is made of resources. Provide a base from which progress can be measured.

Strategic planners using a balanced scorecard

Develop metrics Collect data Analyze that data from four organizational perspectives -Financial -Customers -Business processes -Learning and growth

Diagnosis-Related Groups (DRGs) and the Prospective Payment System (PPS)

Diagnosis-related groups (DRGs) are predetermined payment schedules that reflect historical costs for the treatment of specific patient conditions. With DRGs, hospitals join the prospective payment system (PPS), whereby they receive a specified amount for each Medicare patient's admission, regardless of the actual cost of care.

Discouraging Socialization

Do not make yourself overly accessible. Interrupt a rambling person. Avoid promoting socialization. Schedule long-winded pests.

Personal Characteristics of Time Wasting

Does not understand time planning Cannot distinguish what is important from what is not Underestimates time and effort needed to accomplish tasks Makes too many rules or procedures or approvals Anxiety about planning robs energy Does not look at the standard of work necessary

Lewin's Driving and Restraining Forces

Driving (facilitators): forces that push the system toward change Restraining (barriers): forces that pull the system away from change

Responsibility Accounting

Each of an organization's revenues, expenses, assets, and liabilities is someone's responsibility. As a corollary, the person with the most direct control or influence on any of these financial elements should be held accountable for them, usually the leader-manager. The unit manager also can best monitor and evaluate all aspects of a unit's budget control.

Tell whether the following statement is true or false: For change to be effective, it should be immediate and sweeping.

False Change should be gradual and carefully planned rather than sudden

Tell whether the following statement is true or false: According to Bran, one should master personal time by setting many priorities and sticking to them.

False Rationale: According to Bran's 12 Habits to Master Time Management, an individual should set few priorities and stick to them.

Tell whether the following statement is true or false: Cost containment is primarily the responsibility of the health-care organization as a whole.

False Rationale: Cost containment is the responsibility of every health-care provider.

Tell whether the following statement is true or false: The planning process differs depending on the period of time involved.

False Rationale: Planning involves the same process regardless of the period involved.

Tell whether the following statement is true or false: The young organization is characterized by low energy and resistance to change.

False Rationale: The young organization is characterized by high energy, movement, and virtually constant change and adaptation.

Why Do Plans Fail?

False assumptions Not knowing overall goal Not enough alternatives Inadequate time or other resources Low motivation levels Sound strategies not used Inadequate delegation of authority Not recognizing organizational goals and needs Planning too narrow in scope—not recognizing community, legal, and licensing requirements

Creating a Time-Efficient Work Environment

Gather all supplies needed before starting an activity. Group activities that are in the same location. Use time estimates. Document nursing interventions as soon as possible after they are completed. Always strive to end the work day on time.

Goal, Objective, Policies, Procedures, and Rules

Goal—the desired result toward which effort is directed Objective—how the goal will specifically be achieved (includes time frame and is measurable) Policies—plans reduced to statements Procedures—step-by-step process Rules—plans that specifically define acceptable choices of action

Types of Managed Care Organizations

Health maintenance organization (HMO) - Point-of-service (POS) - Exclusive provider organization (EPO) Preferred provider organization (PPO)

The Time Inventory

Helps the individual determine how much time he or she spends on a particular task and what time of day he or she is most productive. It is important to maintain the time inventory for several days or even weeks and to repeat it annually to see if long-term changes have been made.

Barriers to Identifying Long-Term Needs in Planning

Hospital systems filling the gaps in health care Value versus volume Revenue management versus cost management Health-care costs and government regulation Rapidly changing technology Consumer focus Interprofessional collaboration Scientific advances

Personal Organization—Knowing and Understanding How and Why You Use Time or Set Priorities as You Do

How do you waste time? What types of work you avoid? What is the best time of day for you to work? How long you can work before becoming nonproductive?

Daily Planning Actions to Utilize Time

Identify key priorities to be accomplished that day. Determine the expected level of achievement of a prioritized task. Assess the staff assigned to work with you. Review the short- and long-term plans of the unit. Plan ahead for meetings. Allow time to assess progress of goal attainment. Take regular breaks and use electronic calendars.

Advocating against implementing a new hospital computer system is an example of which type of planning? Reactivist Inactivist Preactivist Proactivist

Inactivist

Which is a pitfall of list making? Being too flexible Looking at one's list too often Including an unreasonable number of items on one's list

Including an unreasonable number of items on one's list

Budgeting Methods

Incremental budgeting Zero-based budgeting Flexible budgeting Performance budgeting

Stage 2: Contemplation

Individual considers making a change.

Stage 4: Action

Individual modifies his or her behavior.

Criticisms of Managed Care

Loss of existing physician-patient relationships Limited choice of physicians for consumers Lower level of continuity of care Reduced physician autonomy Longer wait times for care Consumer confusion about the many rules to be followed

Forces restraining from reaching the goal

Low energy level Limited financial resources Unreliable transportation Time with family already limited

Integrating Leadership and Management Functions in Planned Change

Manager: mechanic who implements the planned change Leader: inventor or creator of the planned change Both leadership and management skills are necessary in planned change.

Managing Time

Managing time is difficult if a person is unsure of his or her priorities for time management, including personal short-term, intermediate, and long-term goals.

Personal Time Management

Managing time is difficult if a person is unsure of his or her priorities for time management, including personal short-term, intermediate, and long-term goals.

Planning Hierarchy

Mission Philosophy Goals Objectives Policies Procedures Rules

Stage 1 Precontemplation

No current intention to change

Fiscal Planning

Not intuitive; a learned skill that improves with practice An important but often neglected dimension of planning Should reflect the philosophy, goals, and objectives of the organization A skill increasingly critical to nursing managers because of increased emphasis on finance and "big business" of health care

NCH/PPD

Nursing hours worked in 24 hours/patient census

Forces driving to reach the goal

Opportunity for advancement Status, social gratification Enhanced self-esteem Family supportive of efforts Pay increase

Direction of Change in 21st Century Health-Care Organizations

Organizational restructuring Quality improvement Employee retention

Organizational Aging

Organizations progress through developmental stages. As organizations age, structure increases to provide greater control and coordination. The young organization is characterized by high energy, movement, and virtually constant change and adaptation. Aged organizations have established "turf boundaries," function in an orderly and predictable fashion, and are focused on rules and regulations.

Resistance to Change

Perhaps the greatest factor contributing to the resistance encountered with change is a lack of trust between the employee and the manager or the employee and the organization.

What is generally the area of most expenditures? Operating budget Supplies Personnel budget Capital budget

Personnel Budget

Strategic Planning

Planning has many dimensions, including time span and complexity or comprehensiveness. Complex plans are long-range or strategic plans. Strategic planning typically examines an organization's purpose, mission, philosophy, and goals in the context of its external environment.

"DO NOW" = Setting Priorities

Priority setting is perhaps the most critical skill in good time management because all actions we take have some type of relative importance. Making lists

Cost-Effectiveness

Producing good results for the amount of money spent. Expensive items can be cost-effective and inexpensive items may not. Must take into account factors such as anticipated length of service, need for such a service, and availability of other alternatives.

Patient Protection and Affordable Care Act

Put in place comprehensive insurance reforms that were to be phased in over a 4-year period: - New Patient Bill of Rights - Bundled payments - Accountable care organizations - Hospital value-based purchasing - The medical home - Health insurance marketplaces

Procrastination

Putting off something until a future time, postponing, or delaying needlessly Not a character flaw, but a set of behaviors that develop over a period of time and that can be changed The dread of doing a task uses more time and energy than doing the task itself

Presenting employees with the pros and cons of a new system to be implemented is an example of which type of strategy? Rational Normative Power

Rational Rationale: A rational change agent uses empirical reasoning as a tool for initiating change.

A nurse-manager is attempting to restructure the unit to prevent understaffing of the nurses. The nurses agree this is a needed change. What type of change strategy would be most effective? Rational-empirical strategies Normative-reeducative strategies Power-coercive strategies None of the above

Rational-Empirical Strategies

Classic Change Strategies

Rational-empirical strategies: used when there is little anticipated resistance to the change or when the change is perceived as reasonable Normative-reeducative strategies: use group norms and peer pressure to socialize and influence people so that change will occur Power-coercive strategies: feature the application of power by legitimate authority, economic sanctions, or political clout of the change agent

Chaos Theory

Really about finding the underlying order in apparently random data Determining this underlying order, however, is challenging, and the order itself is constantly changing. Changes in outcomes are not proportional to the degree of change in the initial condition

Cost Containment

Refers to effective and efficient delivery of services while generating needed revenues for continued organizational productivity The responsibility of every health-care provider, and the viability of most health-care organizations, today depends on its ability to use its fiscal resources wisely.

Moral Hazard

Refers to the propensity of insured patients to use more medical services than necessary because their insurance covers so much of the cost

Planned Change Versus Accidental Change

Regardless of the type of change, all major change brings feelings of achievement, pride, loss, and stress. Planned change, in contrast to accidental change or change by drift, is change that results from a well-thought-out and deliberate effort to make something happen.

Making Lists

Remember that lists are planning tools and thus must be flexible! Reexamine items that remain on the list day after day. Perhaps they do not need to be done or they need to be broken down into smaller tasks. Only put as many items on the daily list as can reasonably be accomplished in a day.

Factors Influencing the Future of Health Care

Robotic technology Biomechatronics Biometrics and smart cards Point-of-care testing Telehealth and the Internet Growing elderly population Nursing shortages in acute care hospitals

The SMART Approach to Studying

Set specific, clear goals to be accomplished Record your progress as measurable progress maintains your interest Identify the steps needed to accomplish your goals Be realistic about your time constraints and set goals that can be accomplished within these constraints Set a time frame and plan for this

Manageable Tasks

Some projects are not accomplished because they are not broken down into manageable tasks.

Stages of Change Model (Burrowes and Needs, 2009)

Stage 1: Precontemplation Stage 2: Contemplation Stage 3: Preparation Stage 4: Action Stage 5: Maintenance

Strategies for Successful Planning

Start planning at the top. Keep planning organized, clear, and definite. Do not bypass levels of people. Have short- and long-range plans and goals. Know when to plan and when not to. Keep target dates realistic. Gather data appropriately. Be sure objectives are clear. Remember, interpersonal relationships are important.

Critical Pathways

Strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care Predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery.

SWOT

Strengths are those internal attributes that help an organization to achieve its objectives Weaknesses are those internal attributes that challenge an organization in achieving its objectives Opportunities are external conditions that promote achievement of organizational objectives Threats are external conditions that challenge or threaten the achievement of organizational objectives

Complex Adaptive Systems Change Theory

Suggests that the relationship between elements and agents within any system is nonlinear and that these elements are the key players in changing settings or outcomes Olson and Eoyang (2001) suggest that the self-organizing nature of human interactions in a complex organization leads to surprising effects.

Medicare and Medicaid Managed Care

The Centers for Medicare and Medicaid Services is now the largest purchaser of managed care in the country. MCOs receive reimbursement for Medicare-eligible patients based on a formula established by the CMS, which looks at age, gender, geographic region, and the average cost per patient at a given age. Then, the government gives itself a 5% discount and gives the rest to the MCO.

Refreezing

The change agent assists in stabilizing the system change so that it becomes integrated into the status quo

Unfreezing

The change agent convinces members of the group to change or guilt, anxiety, or concern are elicited

Movement

The change agent identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed restraining forces

Types of Budgets

The personnel budget The operating budget The capital budget

Resistance—The Natural and Expected Response to Change Individuals' resistance typically depends on four things:

Their flexibility to change Their evaluation of the immediate situation The anticipated consequences of the change Their perceptions of what they have to lose and gain

Subordinate Input in Strategic Plans

There is increasing recognition of the importance of subordinate input from all levels of the organization to give strategic plans meaning and to increase the likelihood of their successful implementation.

Stage 3: Preparation

There is intent to make a change in the near future.

Tell whether the following statement is true or false: The Centers for Medicare and Medicaid Services is now the largest purchaser of managed care in the country.

True The Centers for Medicare and Medicaid Services is now the largest purchaser of managed care in the country. Of the total Medicaid enrollment in the United States in 2009, approximately 72% of participants are receiving Medicaid benefits through managed care (NCSL, 2013). In addition, all states except Alaska and Wyoming have all or a portion of their Medicaid population enrolled in an MCO (NCSL, 2013).

Kurt Lewin's Change Theory

Unfreezing Movement Refreezing

Length of Strategic Plan

Unlike the 20-year strategic plans of the 1960s and 1970s, most long-term planners today find it difficult to look even 5 years in the future.

Forecasting

Using available historical patterns to assist in planning Examining present clues and projected statistics to determine future needs

PPACA's Payment Reform Provisions

Value-based purchasing Accountable care organizations (ACOs) Bundled payments The medical home The health insurance marketplace

Qualities of Change Agents

Visionary Risk taker Flexible Excellent communicator Creative Sensitive Current

Involvement in Change

Whenever possible, all those who may be affected by a change should be involved in planning for that change. When information and decision making are shared, subordinates feel that they have played a valuable role in the change.

Inactivists

consider the status quo as the stable environment and they spend a great deal of energy preventing change and maintaining conformity.

Planning

deciding in advance what to do, who is to do it, how it is to be done, and when it is to be done. proactive, deliberate process required of all managers. guide for action in reaching a goal and requires flexibility and energy. requires management skills such as data gathering, forecasting, and transforming ideas into action.

Forcasting

involves making an educated budget estimate using historical data

Because a plan is a guide to reach a goal,

it must be flexible and allow for readjustment as unexpected events occur.

Managers who are uninformed about the legal, political, economic, and social factors affecting health care ....

make planning errors that may have disastrous implications for their professional development and the financial viability of the organization.

Reactivists

plan after a problem exists.

Proactive

planning style is always the goal Is dynamic, and adaptation is considered to be a key requirement because the environment changes so frequently aka Interactive considers the past, present, and future and attempts to plan the future of an organization rather than react to it

Because change disrupts the homeostasis or balance of the group

resistance should always be expected

Without adequate planning ...

the management process fails, and organizational needs and objectives cannot be met.

Two mistakes common in planning

underestimating the importance of a daily plan and not allowing adequate time for planning

Preactive

utilize technology to accelerate change and are future-oriented.